After two years of debate, public lacks full understanding of Affordable Care Act, survey shows
As a conservative who tends to favor Republicans and limited government, Gene Hutchins of Affton wouldn't be expected to be a cheerleader for the Affordable Care Act. But he has warmed up to a few of its provisions. He backs the rule forbidding insurers to deny coverage to people with pre-existing conditions. He also likes ACA's plans for states to set up insurance exchanges to help buyers compare prices and benefits to get the most value for their money.
In his overall dislike of ACA, Hutchins, 63, represents one side of a sharp partisan divide. By embracing a few provisions, Hutchins mirrors those who find some good in a law that has yet to gain solid footing in Missouri and perhaps nationwide as well.
"That has been one consistent hallmark of the law: The parts have always been much more popular than the whole," observes Claudia Deane, associate director for public opinion and survey research at the Kaiser Family Foundation.
Shadow cast by individual mandate
The so-called individual mandate — the requirement that a person must have health insurance or pay a fine — appears to have generated the most controversy. This provision has been the most disliked part of the law, polls repeatedly show. Deane says that matter was controversial due to "a long-standing streak in public opinion that Americans do not like the idea of an overactive federal government. They don't like the government telling them what to do."
That's in keeping with general findings in a Pew Research Center survey in June showing growing opposition to government’s role in health care. That survey found that 59 percent felt the government had become too involved in health care. "That’s up 13 points since 2009," Pew said, but it added that 82 percent of the public also felt that more government input was needed to make health care more affordable and accessible.
Sidney Watson, a St. Louis University law professor, isn't sure the general public has been as hung up as politicians have over the mandate issue. "There's a difference in what gets challenged in a politically motivated lawsuit and public opinion," she says, referring to the litigation that several states brought against ACA's mandate. The court upheld that provision.
Watson suggests that use of the term "mandate" might have influenced what people thought even if they had no idea what the term actually meant before the court ruling. "First of all, it's not a mandate," she says. "Nobody has to buy insurance. It's a penalty for people who don't buy it, and (the penalty) affects only about 2 percent of people."
What's ACA all about?
For all the debate over ACA since it became law in 2010 and was upheld by the U.S. Supreme Court this summer, the public remains misinformed about much of the legislation, Deane says. Kaiser data show that tax credits to small businesses for health insurance are popular among 80 percent of Americans. Yet only 49 percent of those in Kaiser polls knew that this provision was part of ACA. Large majorities in the polls favored a number of other health reforms, but only 35-45 percent of those polled were aware that such provisions are all part of ACA, Deane says.
- easy-to-understand summaries of insurance plans,
- an end to the "doughnut hole" or out-of-pocket prescription expenses for seniors,
- elimination of gender bias in ratings that cause women to pay more for insurance than men,
- and a requirement that insurers spend a high percentage of premiums on medical care and less on marketing.
The lack of knowledge may be due in part to people simply not paying attention to details of the act because other issues, such as the economy, are on their minds. In addition, Deane says the polls show that many don't believe ACA affects their lives, but they might take note once they receive its benefits. For now, however, many regard the law as just another ideological fight in Washington, "another thing politicians are arguing about," Deane says.
Others say the public's view of the law is distorted by misleading anti-ACA attacks, such as false claims that the law would set up "death panels." Deane points out that no such provision by any name is included in the law.
Skeptics, like Hutchins of Affton, say he understands what prompted some to raise the issue. He says circumstances may eventually arise when care would be rationed for elderly people suffering from certain costly catastrophic illnesses.
Given his experiences, Hutchins would seem like a natural supporter of ACA. He has survived periods without health insurance after a layoff years ago as an IT worker. Now retired and too young to qualify for Medicare, he is insured through his wife's policy. He speaks of times when he struggled to come up with $234 out of pocket for prescriptions and the times when insurer after insurer refused to write him a policy or imposed a waiting period for covering his pre-existing condition of diabetes. That experience probably explains why he likes the protection ACA gives people with pre-existing conditions.
But he remains unconvinced that ACA is the answer. Injecting more competition in the private insurance market would fix the problem, he said. "It would make insurance more affordable, and more people could buy it," he says.
On the other side of the ACA divide are those who think people are misinformed because the law is complex and difficult to understand. That's the view of Patricia Brennan, a Collinsville retiree, who says she's 69 chronologically and 39 psychologically. She acknowledges what she says is serious public distrust of government among ACA opponents.
Examples, she says, are signs she has seen at anti-ACA demonstrations, telling government officials to keep your "hands off Medicare." She notes that the federal government's hands always have been in the popular Medicare program, a point that she says ACA opponents don't seem to appreciate even if they receive Medicare. It's as if the opponents are saying, "don't confuse me with the facts," Brennan feels.
On the other hand, many foes of ACA say they are far from confused. One is Mike Pomatto, 45, a Libertarian who teaches at Whitfield School. He says he dislikes the law because it "increases an already immense bureaucracy and empowers politicians and others not affiliated with the health-care profession."
As the debate persists over ACA, the Department of Health and Human Services tries to educate the public on the law's benefits. Among other things, the agency has issued a timeline highlighting the benefits:
- Cost-free preventive medical services for many elderly Americans.
- Creation of accountable care organizations under which physicians and other providers will work as teams to improve care quality.
- Expansion of Medicaid to cover many poor uninsured people.
Debate over Medicaid expansion
As an incentive to states to expand Medicaid, the federal government will pay 100 percent of the added cost for the first three years, beginning in 2014. Then the federal share will drop to 90 percent with each state covering the rest.
Medicaid expansion is projected to extend health benefits to an additional 200,000 needy residents in Missouri and 420,000 in Illinois.
Amy Blouin, executive director of the Missouri Budget Project, argues that the public needs better information so that it understands that Medicaid expansion is a good deal. She says Missouri "only needs to invest $431 million over the first five years of implementation" of the expansion, with the federal government covering full expansion for three years and 90 percent of the cost by 2020 and beyond.
A Kaiser study projects that Missouri would get $8.3 billion in federal Medicaid assistance between 2014 and 2019. The study says Illinois would have to put up $1.2 billion and get $19.2 billion in federal help. The amount each state would contribute would be no higher than 0.17 percent of each state's GDP for 2011.
Blouin's and Kaiser's figures on Missouri's contribution are higher than some others projections because she and Kaiser don't take into account the fact that because Missouri's hospital tax will help offset the amount of general revenue Missouri would need to finance Medicaid expansion.
In any case, Blouin adds that the federal contribution would have the added benefit of helping Missouri’s "struggling economy by creating jobs and new state tax revenue from the growth of personal income."
Another local nonpartisan group trying to cut through misinformation is the Missouri Foundation for Health. But convincing the public of the value of ACA has been an uphill battle, says Thomas McAuliffe, the organization's policy analyst. The group's polls, like national ones by Kaiser, have shown that Missouri residents are skeptical of the law even if they say they like many provisions.
McAuliffe says many arguments against expanding Medicaid distort the importance of this federal-state health insurance program for the needy. "When people say, 'Obamacare', what does that mean? Because they don't know what it means, they are waiting for people to filter the information for them. As a result, they have an unfavorable opinion because of the filters."
McAuliffe gives the Republican Party pat on the back for doing "a very great job of mobilizing or controlling the issue," and he adds that the Obama administration "has not done a very good job in educating people and getting the facts out."
Under the initial ACA law, states would have been required to expand Medicaid or lose some of their existing federal Medicaid matching money. But the Supreme Court ruled that the government couldn't take back any of that funding; it also ruled that ACA must make Medicaid expansion optional rather than mandatory. That has led some Missouri politicians to say they want the state to refuse the federal money for Medicaid.
Impact of political polarization
McAuliffe also believes that the health-care debate is symptomatic of something bigger in the political system, whether the issue is education, the economy, transportation or health care.
"We are so polarized that health care is just a placeholder," he says. He adds that "people are willing to believe in fear more than they are in facts. People fear the law is going to take away their doctors, take away their insurance and all these other things. This law actually enables them more than it takes away."
He looks back at the infancy of Social Security, saying "I'm not sure people loved Social Security when it was first passed, but as soon as people started getting checks and started getting the benefits, the opposition faded away."
He says the same transformation could happen once people begin receiving health benefits under ACA. That also the thinking of Bunnie Gronborg, 64, a retiree from Festus. She uses the example of ACA's medical/loss ratio requiring an insurer to give rebates to customers if the insurer has spent less than 80 percent of each premium dollar on health care. Gronborg says rebates are arriving in the mail, accompanied by a letter saying consumers are getting them because of ACA.
As more people personally receive ACA benefits, she believes that support for the law "will rise exponentially."
Unless, of course, "issue fatigue" sets in. That the term Kaiser's Deane uses to describe how growing numbers of Americans seem to feel about the debate. Like everything else about ACA, she says this issue splits along partisan lines.
"Most Republicans are insisting that it's important to keep discussing the issue," Deane says, while "a large majority of Democrats and a small majority of Independents would like to move on."